curs 3 respirator eng radiology lecture
TRANSCRIPT
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THE RESPIRATORY SYSTEM AND THE MEDIASTINUM
Radio-imaging - lecture III
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ACUTE PNEUMOPATHIES
Inflammatory non-suppurative
Inflammatory suppurative : Primary : abscess, pulmonary gangrene, diffuse pulmonary
suppuration Secondary : complication of
pneumonia, bronchiectasis, pulmonary cysts
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ETIOLOGICAL CLASSIFICATION
ETIOLOGICAL CLASSIFICATION OF PNEUMONIA - BACTERIAL - Streptococcus pneumoniae ( Pneumococcus )
- Staphilococcus aureus - Streptococcus pyogenes - Klebsiella pneumoniae ( Friedlander b.) - Other Gram-negative germs: - Pseudomonas aeruginosa ( Pyocyanic b. )
- Escherichia coli - Proteus
- Serratia - Haemophilus influenzae - Legionella pneumophila - Mycobacterium - Bordetella pertussis - Salmonella typhi and paratyphi - Brucella - B. anthracis , etc. -
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-VIRAL : - Ifluenza and parainfluenza virus: - Varicella - Measles - Respiratory syncytial virus - Adenovirus - Enterovirus - Herpes virus - Cytomegalic virus - CHLAMIDII : - Chlamidia psittaci - Chlamidia trachomatis - RICKETTSII : - Coxiella burnetti (Q fever) - MYCOPLASMa : - Mycoplasma pneumoniae - FUNGI : - Actinomyces israelii - Aspergillus fumigatus - Candida albicans - Coccidioidomyces - Histoplasma capsulatum - PROTOZOA: - Pneumocystis carinii - UNINFECTIOUS: - Aspiration pneumonia (Mendelson syndrome) - Toxic gas inhalation pneumonia - Radiation pneumonia - Lipoid pneumonia GHERASIM 2002
EIOLOGIAL CLASSIFICATION
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INFLAMMATORY PNEUMONIA (NON-SUPPURATIVE)
Alveolar = pneumonia
Broncho-alveolar = bronchopneumonia
Interstitial = interstitial pneumonia
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ALVEOLAR PNEUMONIA - perioada de stare -
1. Lobar or segmental2. Homogeneous opacity3. Variable intensity depending on
extent4. Sharp and linear outline (fissure)5. Blurred outline (the area not outlined
by fissure) 6. Doesn’t change the surrounding
structures7. Doesn’t change the pulmonary volume8. Air bronchogram and alveologram
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Dorsal segmentitis, right superior lobe
PA RL
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Middle lobe pneumonia, lateral segmentsmall pleural effusion in the right CP angle
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Congestion, right inferior lobe
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Bilateral air-space filling syndrome
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THE EVOLUTION OF PNEUMONIA
Complications : - abcess - pleural effusion
Resorbtion: - homogeneous - unhomogenous : - chess
board -
pseudocavitary
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Fowler segment abcess
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Pneumonia: evolution
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BRONCHOPNEUMONIA1. Broncho-alveolar inflammation2. Multiple round opacities3. Micro or macronodular4. Medium intensity5. Blurred outline6. Unhomogeneous dissemination
(bronchal)
7. The aspect changes rapidly (from one exam to the other)
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Bronchopneumonia
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Staphylococcal pneumonia (bronchopneumonia)
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INTERSTITIAL PNEUMONIA
Etiology: - viral, - bacterial (mixed p.) - mycoplasma - chlamydia - rickettsia, - protozoa
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INTERSTITIAL PNEUMONIA1. Accentuated peribronchovascular
interstitium
2. Reticular infrahilar pattern
3. Opaque uni- or bilateral bands in the inferior parts
4. Micro- or macronodular opacities
5. Moderately enlarged pulmonary hila
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Viral pneumonia
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Varicella (Chickenpox) virus pneumonia
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Primary pulmonary abscess
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IMAGING TECHNIQUES IN PLEURAL EFFUSIONS
Thoracic x-ray:– orthostatic– lateral decubitus with horizontal
beam
Thoracic ultrasound
CT
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ETIOLOGY OF PLEURAL EFFUSIONS
Neoplastic------------------------------ 45% Infectious ------------------------------ 21%
– Tuberculous 10%– Bacterial 9%– Viral 1%– Fungal 1%
Cardiac---------------------------------- 12% Pulmonary infarction------------------ 3% Cirrhosis ------------------------------------ 2% Collagen diseases ------------------------- 1% Other ------------------------------------ 5% Unknown cause --------------------10% !!!
HAUSHEER 1985
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RADIOLOGIC CLASSIFICATION OF PLEURAL EFFUSIONS
EFFUSIONS:– FREE in the main pleural cavity-
quantity:• small• medium • large
– LOCULATED • in the main pleural cavity• in the fissures• in the mediastinal pleural space• in the diaphragmatic pleura
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Free pleural effusion
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Free pleural effusion
ultrasound
left lateral
right lateral
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Pleural effusion
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Pleural effusion
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Loculated effusions
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Loculated pleural effsuions
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Loculated pleural effusions
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“Remember”PneumothoraxPleural calcificationsFibrothorax
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Mesothelioma benign
malignant
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BRONCHO-PULMONARY TUMORS
Radiologic aspects
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BENIGN TUMORS
Benign tumors: - adenoma, - fibroma, - hamartoma, - lipoma, - condroma;Radiology :- Round solitary pulmonary opacity
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RADIOLOGIC FEATURES OF BENIGN TUMORS
- regular outline, sharp borders - intensity depends on the size - homogeneous structure - calcifications (hamartoma) - ( intra-tumoral
calcification does not always mean benign, see “scar cancer”)
- no alterations of the surrounding parenchyma - slow growth > 12 months
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Bronchal adenoma
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Main clinical signs which suggest lung cancer (LC)
1. Local signs: – Cough 45 - 75%– Weight loss 20 – 70%– Dyspnea 40 – 60%– Chest pain 30 – 45%– hemoptysia 25 – 35%– none 2 – 5% !!!
2. Loco-regional signs: – Dysphonia – recurrent laryngeal nerve– Phrenic paralysis – phrenyc nerve– Dysphagia – lymph nodes– SVC syndrome– Pleural or pericardial effusion
3. Paraneoplastic syndromes: endocrine, neurologic, musculoskeletal, hematologic, etc.
Kraut , 2000
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THE 4 MAIN HISTOLOGIC TYPES OF LC IN EVERY DAY PRACTICE
Scuamous cell carcinoma ( 40% ) – mostly on main bronchi
Adenocarcinoma ( 20-30% ) - periphery, but also central
Large cell carcinoma( 20% )Small-cell carcinoma ( 10% )“Non – small” cancer
– Scuamous cell carcinoma – adenocarcinoma– Large cell carcinoma
Small-cell carcinoma - non-surgical, responsive to chemo- and radiotherapy
Surgical resection if possible
Travis 1999
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RADIOLOGIC TYPES OF LC
Central (hilar) of the large bronchi– exobronchal– endobronchal (stenosis
atelectasis)
Peripheral
Bronchioloalveolar carcinoma
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CENTRAL BRONCHAL CANCER (HILAR)
endobronchal
exobronchal
mediastino-pulmonary
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Other lesions may coexist
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ENDOBRONCHAL CANCER - CONSEQUENCES
Bronchal obstruction: - complete =ATELECTASIS
- incomplete :1. Expiratory valve =
hypertranslucency2. Insufficient inspiration =
hypoventilation +pneumona
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Pulmonary tumor - atelectasis
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Pulmonary tumor - atelectasis
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Pulmonary tumor - pneumonia
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Pulmonary tumor – hilar type
OAD
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PRIMARY PERIPHERAL PULMONARY TUMORS
Broncho-pulmonary: - non-differentiated carcinoma
- adenocarcinoma - bronchioloalveolar
carcinoma
Other origins: - sarcoma - neuroblastoma - pneumoblastoma - melanoma
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Regular/irregular outline
Sharp border
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Peripheral cancer – malignant outline
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FEATURES OF THE MALIGNANT PULMONARY NODULE
Size > 4 cmMalignant outlineIncrease (doubling of pulmonary tu. volume) :
3-6 monthsAssociated with: - hilar lymph nodes - lysis of ribs - pleural effusions - pulmonary metastases (smaller
than the primary tumor)o Complications: central necrosis/vascular
effusion
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Pulmonary tumor – peripheral type
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Peripheral LC with enlarged lymph nodes
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Peripheral LC with enlarged lymph nodes
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Pulmonary tumor - necrosis
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Pulmonary tumor - necrosis
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CT
LC – lymph nodes/rib lysis/vascular invasion/necrosis
CT
MRI
CT
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LC – mediastinal invasion
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PANCOAST TOBIAS
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Adenocarcinoma
Male, 41, pain of the right shoulder
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Pulmonary tumor – brochioloalveolar type
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METASTASES OF LCPulmonary metastatic extension
– Metastases– Lymphangitis carcinomatosa
Tumoral extension towards the mediastinum
Tumor extension towards the chest wallLocal and regional extension
– Mediastinal lymph nodes homo- and hetero-lateral– Supraclavicular lymph nodes
Distant extension– brain – adrenals– liver– bone
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THE MOST COMMON SOURCES OF PULMONARY METASTASES
1. Breast c.2. Bone c.3. Thyroid c.4. Seminoma, prostate c.5. Uterine c.6. Digestive tract c.7. Renal c.
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Metastases – nodular type
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Metastases – nodular type
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Metastases – thyroid cancer
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Milliary carcinomatosis
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Lymphangitis carcinomatosa
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Solitary pulmonary metastasis
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PET SCAN